Review articleThe effect of nurse-led education on hospitalisation, readmission, quality of life and cost in adults with heart failure. A systematic review
Introduction
Heart failure (HF) is a syndrome with a generally poor prognosis, regardless of the use of device therapy and pharmacological interventions [1], [2], [3]. It remains the chief reason for hospitalisation in adults over the age of 65 years [4]. Readmissions, debilitating symptoms and poor QoL are characteristic of patients with HF [5], [6]. Globally, there are approximately 26 million HF patients with the incidence expected to rise 25% by 2030 [1], [7]. In the mild to moderate classification of HF, one-year survival is estimated at 80–90%. However, in severe HF, the one-year survival estimation is 50—60% [8]. The annual cost of HF is approximated at $108 billion worldwide [9]. This is expected to rise owing to an ageing population and increasing prevalence of factors such as obesity [5]. The main expenditure relating to HF is on hospitalisation, followed by pharmacotherapies and community support [10], [11], [12].
Multiple factors contribute to a decline in patients with HF, resulting in hospitalisation and decreased quality of life (QoL). These pertain to the patient, healthcare providers, and health and economical systems [13]. Lack of social support, absence of a partner and living alone constitute a risk for rehospitalisation [6], [14], [15]. Improving self-management skills through disease management programs have shown favourable outcomes in adults with HF, particularly on symptoms, wellbeing, functioning, morbidity and prognosis [16].
Risk models relating to psychosocial factors have been developed to identify and target individuals in risk of adverse events such as rehospitalisation [14], [17]. Due to the limitations in medical treatment and the significant economic burden of HF, primary and secondary prevention strategies including education have been sought [9]. Several disease management programmes have been trialled to reduce cost, hospitalisation and improve QoL of adults with HF [3]. However, these often include a multidisciplinary approach and result in large expenditures [18]. Thus, nurse-led interventions in disease management may prove more cost-effective in HF management. Additionally, self-care has become an important component in HF management with the primary objective of teaching patients self-care, increase compliance and self-efficacy, improve QoL and reduced healthcare costs [8], [19].
The main objectives for HF management are slowing or stopping the progression of HF, managing symptoms and preventing hospitalisation [20]. The practice guidelines in USA, Europe and Australia highlight patient education as a key component in establishing an effective management regimen for adults with HF [20], [21], [22].
Many hospital admissions relating to HF are preventable [23]. Additionally, poor HF related knowledge has been linked to issues such as medication non-compliance [24], [25]. These aspects emphasise the importance of patient education. Ideally, the rationale is to increase patients’ knowledge, which in turn, leads to improved self-care behaviour and decrease adverse outcomes [23] such as hospitalisation and cost.
The study aim was to identify evidence on the effect of nurse-led community education on readmission, hospitalisation, QoL and cost in adult patients with HF.
Patient education is an integral part of a nurse’s role. It has been shown to reduce hospitalisation and readmission. Face-to-face education sessions delivered by nurses to adults with HF have shown to improve disease management knowledge [26]. When comparing the amount of time healthcare providers spend with patients, nurses tend to interact and spend considerably more time with patients. As such, the rapport and relationship nurses build with patients has been shown to influence patient outcomes including adherence to treatment, satisfaction, and understanding of information [27]. Previous literature has identified patient dissatisfaction with physicians not providing understandable explanations of disease management when information was presented to adults with HF [28].
The most appropriate types of studies to address the effectiveness of an intervention are randomised controlled trials (RCTs) [29].To establish this, we reviewed RCTs that included nurse-led education as an intervention in which the end points were readmission, hospitalisation, QoL and/or cost.
Section snippets
Methods
This review is an analysis of RCTs focused on nurse-led 1:1 patient education of adults living in the community.
Search strategy
For the purposes of this review, a comprehensive literature search was conducted with the assistance of a research librarian using the electronic databases CINAHL, PubMed and Google Scholar for RCTs. An initial search was conducted to identify index terms, which were then used in a wide-ranging search. Additionally, further studies were hand searched from reference lists of articles for inclusion. Google Scholar was used to identify grey literature. Only studies published in the English
Type of participants
This review considered all patients 18 years and older, with a diagnosis of HF regardless of severity, duration or co-morbid conditions.
Types of intervention
Studies evaluating community based, nurse-led patient education interventions relating to HF that potentially impacted hospitalisation and hospital readmission rates, QoL and/or cost were considered for inclusion. For this review, nurse-led education was defined as an educational intervention designed towards an individual patient and which was driven and
Assessment of methodological quality
All studies were assessed for methodological quality prior to inclusion in the review. The assessment tool used was the Clinical Appraisal Skills Programme (CASP) tool for RCTs [30]. The CASP tool provides an evidence-based approach for assessing the quality, quantity and consistency of specific study designs [30], [31]. Evidence was appraised systematically through a checklist that contains 11 questions relating to the validity of a study, the outcomes and the usefulness of the results. The
Data collection process
Data from eligible RCTs was extracted and collated in tables. Headings and data collection topics were discussed and agreed on between authors. For the purposes of this review, an electronic data collection tool was not used. Data was collected and is presented in Table 3.
Overview
This systematic review identified that nurse-led patient education had a positive impact on outcome measures. Three studies showed that nurse-led education reduced hospital readmission [32], [33], [34]. Two studies showed that nurse-led education led to a reduction in hospitalisation [35], [36] and one study reported no difference in hospitalisation when compared to usual care [37]. Two studies found that nurse-led education improved QoL [32], [38]. Two studies suggested that nurse-led
Discussion
This systematic review identified seven articles examining the effect of 1:1 nurse-led patient education on hospitalisation, readmission, QoL and cost in community-dwelling adult patients with HF. The results of this review suggest that nurse-led education can improve QoL, reduce hospitalisation and readmission. In addition, two of the four studies included in this review concluded this type of education intervention is cost-effective.
Hospitalisation
The results in this review suggest that nurse-led education
Limitations
Consensus was reached by the authors not to use meta-analysis in this review. A meta-analysis was not considered feasible owing to the diversity of the primary studies included; a factor that can render meta-analysis meaningless [67]. While the CASP tool was used to assess methodological rigour of the included studies, external validity was not measured. The setting of the trials differed (country and community setting); selection of participants (eligibility and exclusion criteria differed);
Author contributions
All authors contributed to the study design and conception, as well as data interpretation. HR was responsible for data acquisition in this review. All authors contributed to data analysis and drafting the manuscript. HR, RS and VB critically revised the manuscript for important intellectual content. All authors gave final approval of the version of the manuscript for submission.
Disclosures
The authors have no relevant financial relationships to disclose.
References (68)
The global health and economic burden of hospitalizations for heart failure: lessons learned from hospitalized heart failure registries
J. Am. College Cardiol. (JACC)
(2014)Multidisciplinary strategies for the management of heart failure patients at high risk for admissionA systematic review of randomized trials
J. Am. Coll. Cardiol.
(2004)Epidemiology and cost of advanced heart failure
Prog. Cardiovasc. Dis.
(2011)Interactive education on CD-ROM—a new tool in the education of heart failure patients
Patient Educ. Couns.
(2002)What are the factors in risk prediction models for rehospitalisation for adults with chronic heart failure?
Aust. Crit. Care
(2012)Heart failure patients with a lower educational level and better cognitive status benefit most from a self-management group programme
Patient Educ. Couns.
(2010)- et al.
Patients’ perceived barriers to active self-management of chronic conditions
Patient Educ. Couns.
(2005) Executive summary: HFSA 2010 comprehensive heart failure practice guideline
J. Card. Fail.
(2010)- et al.
Relationship between improvements in heart failure patient disease specific knowledge and clinical events as part of a randomized controlled trial
Patient Educ. Couns.
(2012) Nurse and patient communication profiles in a home-based telehealth intervention for heart failure management
Patient Educ. Couns.
(2008)
Health literacy and knowledge of chronic disease
Patient Educ. Couns.
Randomized trial of an education and support intervention to preventreadmission of patients with heart failure
J. Am. Coll. Cardiol.
Long-term results after a telephone intervention in chronic heart failure: DIAL (Randomized Trial of Phone Intervention in Chronic Heart Failure) follow-up
J. Am. Coll. Cardiol.
Hospitalization epidemic in patients with heart failure: risk factors, risk prediction, knowledge gaps, and future directions
J. Card. Fail.
Rehospitalization for heart failure: problems and perspectives
J. Am. Coll. Cardiol.
Emergency department visits after hospital discharge: a missing part of the equation
Ann. Emerg. Med.
Predicting the risk of unplanned readmission or death within 30 days of discharge after a heart failure hospitalization
Am. Heart J.
Dyads affected by chronic heart failure: a randomized study evaluating effects of education and psychosocial support to patients with heart failure and their partners
J. Card. Fail.
Worsening heart failure hospitalization epidemic: we do not know how to prevent and we do not know how to treat!
J. Am. Coll. Cardiol.
The effects of nursing interventions to enhance mental health and quality of life among individuals with heart failure
Appl. Nurs. Res.
Quality of life in patients with heart failure: ask the patients
Heart Lung: J. Acute Crit. Care
Chronic heart failure: we are fighting the battle, but are we winning the war?
Scientifica
Epidemiology and aetiology of heart failure
Nat. Rev. Cardiol.
The importance and impact of social support on outcomes in patients with heart failure: an overview of the literature
J. Cardiovasc. Nurs.
The effectiveness of patient-centered self-care education for adults with heart failure on knowledge, self-care behaviors, quality of life, and readmissions: a systematic review, 2014
JBI Library Syst. Rev.
Construction and validation of a questionnaire about heart failure patients' knowledge of their disease
Arq. Bras. Cardiol.
A reevaluation of the costs of heart failure and its implications for allocation of health resources in the United States
Clin. Cardiol.
What are the costs of heart failure?
Europace
An absolute risk prediction model to determine unplanned cardiovascular readmissions for adults with chronic heart failure
Heart Lung Circ.
Association of parther status and disposition with rehospitalization in heart failure patients
Am. J. Crit. Care
Rehospitalization for heart failure: predict or prevent?
Circulation
Lack of improvement of clinical outcomes by a low-cost: hospital-based heart failure management programme
J. Cardiovasc. Med.
ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012
Eur. J. Heart Fail.
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